Answers latest update 2025
To assess the quality of an adult client’s pain, what approach should the nurse use? C
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
A client who has been diagnosed with terminal cancer tells the nurse, “The doctor
told me I have cancer and do not have long to live.” Which response is best for
the nurse to provide?
A) “That’s correct, you do not have long to live” D
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.”
D) “Yes, your condition is serious.”
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first? C
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate
and rhythm. C) Position the
client supine for a few minutes.
D) Assist the client to stand at bedside.
Female unlicensed assistive personnel (UAP) are assigned to take the vital signs
of a client with pertussis for whom droplet precautions have been implemented.
The UAP request a change in assignment, stating she has not yet been fitted for a
,particulate filter mask. What action should the nurse take? D
When evaluating the effectiveness of a client’s nursing care, the nurse first
reviews the expected outcomes identified in the plan of care. What action should
the nurse take next?
A) Modify the nursing interventions to achieve the client’s goals.
B) Determine if the expected outcomes were realistic.
C) Review related professional standards of care.
D) Obtain current client data to compare with expected outcomes.
A policy requiring the removal of acrylic nails by all nursing personnel was
implemented six months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved?
A) Number of the staff-induced skin injuries.
B) Client satisfaction survey.
C) Rate of needlestick injuries by nurses.
D) Healthcare-associated infection rates.
A client with limited tolerance for activity needs to walk in the hallway with
assistance. Which instructions should the nurse give to the unlicensed assistive
personnel (UAP) who assisting with client’s care? (Select all that apply.)
A) Instruct the client about signs of orthostatic hypertension
B) Determine if the client needs to have a gait belt applied
C) Measure the clients vital signs before the
client walks.
D) Offer to assist the client to void prior to
walking in the hall.
,E) Report the onset of any dizziness or light headedness.
A client has begun a long-term maintenance therapy with lithium, which has
a narrow therapeutic index. Which adverse effect is most important for nurse
to include in the teaching plan?
A) Dependence.
B) Toxicity.
C) Interaction.
D) Tolerance.
While interviewing a client, the nurse records the assessment in the electronic
health record. Which statement is most accurate regarding electronic documentation
during an interview?
A) The interview process is enhanced with electronic documentation and allows the client to
speak at a normal pace.
B) Completing the electronic record during an interview is a legal obligation of the examining
nurse.
C) The nurse has limited ability to observe nonverbal
communication while entering the assessment electronically.
D) The dclient’s dcomfort dlevel dis dincreased dwhen dthe dnurse dbreaks deye dcontact dto dtype
notes dinto dthe drecord.
d
A dclient dwho dlives din dan dassisted dliving dfacility ddevelops dcognitive
d impairmentdfollowing da dstroke. dInformed dconsent dis dneeded dto dprovide
d additional dnursing dservices. dWho dshould dnurse dcontact?
A) The dclient’s doldest dliving dchild, da dlawyer, dwho dis dvisiting dfrom dout dof dtown.
, B) A ddaughter d-in-law ddesignated das dthe dclient’s dDurable dPower dof dAttorney d(DPOA).
C) The dclient’s dyoungest dson, didentified dby dfamily dmembers das dthe dfamily dspokesperson.
D) The dclient’s dspouse dwho dlives din dthe dindependent dliving dunit dof dthe dfacility.
A dclient dis din dcontact disolation ddue dto dstage dIV dcoccyx dwound dinfected dwith
d methicillin dresistant dstaphylococcus daureus d(MRSA). dThe dnurse dplans
interventionsdto dprevent dmultiple dre-entries dto dthe dclient’s droom. dIn dwhich dorder
d
d should dthe dnurse dperform dthe dinterventions?
A) Change dcoccyx ddressing, dperform dtracheostomy dcare, drestart dthe dIV.
B) Perform dtracheostomy dcare, dchange dcoccyx ddressing, drestart dthe dIV.
C) Restart dthe dIV, dperform dtracheotomy dcare, dchange dcoccyx ddressing.
D) dChange dcoccyx ddressing, drestart dthe dIV, dperform dtracheostomy dcare.
What dself-care doutcome dis dbest dfor dthe dnurse dto duse din devaluating da dclient’s
recoverydform da dstroke dthat dresulted din dleft- dsided dhemiparesis?
d
A) Promote dindependence dby dallowing dclient dto dperform dall dself-care dactivities.
B) Participates din dself-care dto doptimal dlevel dof dcapacity.